Mihai Strachinaru

Left atrial septal pouch thrombus assessed on three-dimensional transoesophageal echocardiography

The left atrial septal pouch (LASP) is an anatomical entity that came to the attention of the medical community in 2010 when Krishnan and Salazar described it as a possible source of embolism. It is formed by the caudal fusion of the area of overlap of the septum primum and the septum secundum. The …

The left atrial septal pouch as a risk factor for stroke: A systematic review

The left atrial septal pouch (LASP) is formed by incomplete fusion of the septum primum and septum secundum, leaving a cavity open towards the left atrium, but without interatrial shunting. There is no recommendation concerning strategy in the presence of a LASP, especially in the setting of stroke. The aim of this review was to determine whether the LASP could be incriminated as the aetiology of a stroke. We included all pertinent publications on the subject, and calculated hazard ratios for ischaemic stroke and cryptogenic stroke. There were only five case-control studies concerning the LASP, involving 516 stroke patients and 779 controls. Overall LASP prevalence was 21%, with a slightly higher prevalence in the cryptogenic stroke group (26%), but this difference was not statistically significant (P=0.27). In a random-effects meta-analysis, there was no difference between controls and patients with ischaemic stroke (hazard ratio 1.20, 95% confidence interval 0.96-1.53; P=0.14). Cryptogenic stroke appeared more frequently in patients with LASP (hazard ratio 1.53, 95% confidence interval 1.07-2.24; P=0.02), but this was driven by only one severely underpowered study. The published case reports demonstrated that thrombus formation inside the pouch can occur in the presence of major predisposing factors. The LASP can be a site for thrombus formation, leading to embolic events, but its presence does not correlate with an increased incidence of stroke. Associated factors should be taken into consideration in the setting of stroke. Further studies are necessary to validate a possible relationship with cryptogenic stroke.

The Left Atrial Septal Pouch as a Possible Risk Factor for Stroke

The left atrial septal pouch (LASP) is formed by the caudal fusion of the area of overlap of the septum primum and the septum secundum, leaving an opening toward the left atrium. The association between LASP and stroke has not been validated by the previous studies.

Right-sided gothic aortic arch and Kommerell diverticulum

A 16-year-old female consulted our cardiology department for fatigue. During the physical examination we noted a left interscapular systolic murmur, with a blood pressure of 120/80 mmHg on the right arm and 70 mmHg on the left. Her ECG was normal as was her echocardiography, without valvular or congenital disease. An angulated aortic arch, with a …

An atypical evolution of tako-tsubo cardiomyopathy

An 83-year-old woman with a possible history of myocardial infarction presented with acute chest pain and dyspnoea. The electrocardiogram showed no signs of acute coronary syndrome, but Q waves in the anteroseptal leads. The blood tests showed an important elevation of troponin T level. Emergency coronary angiography revealed normal epicardial arteries, but the left ventriculogram demonstrated anterior akinesis and ballooning with normal apical and basal function. An atypical takotsubo cardiomyopathy was suspected and the patient received beta blocker and ACE inhibitor treatment. Two days later the echocardiogram evolved to a classical pattern of apical ballooning with normalization on the follow-up examination 5 weeks from the acute episode. To our knowledge, this is the first case report describing an evolving pattern of wall motion abnormality from an anterior wall ballooning to an apical form.

Tricuspid Regurgitation in Patients with Heart Transplant

In this chapter, an overview of the epidemiology, the pathophysiology, the clinical features, management and prognosis of tricuspid regurgitation in patients post heart transplant will be discussed. An overview of the natural history of severe tricuspid regurgitation and treatment options will be illustrated via a clinical case.

Safety and feasibility of contrast echocardiography for the evaluation of patients with HeartMate 3 left ventricular assist devices

Aims Patients with a left ventricular assist device (LVAD) are challenging to evaluate using conventional imaging techniques, such as standard echocardiography (SE). The aim of this pilot study was to evaluate the potential of contrast echocardiography (CE) for the evaluation of the left ventricle (LV). Methods and results This prospective study included 14 ambulatory patients (mean age 58 ± 9 years, 79% male) with a LVAD (all HeartMate 3, Abbott Laboratories, Chicago, IL, USA). Nine (64%) patients had an ischaemic cardiomyopathy, and 5 (36%) had a non-ischaemic cardiomyopathy. All patients underwent SE and CE using intravenous administration of Sonovue contrast agent (Bracco, Milan, Italy). The echocardiograms were assessed by three observers, using a standard 17-segment model of the LV. Left ventricular end-diastolic volume (LVEDV) was assessed using the biplane Simpson method. The contrast agent was well tolerated by all patients, without any side effects. Overall, SE allowed visualization of 57% of LV segments (135/238) and CE allowed visualization of 79% of LV segments (187/238), P < 0.001. Per patient, SE resulted in visualization of 9.6 ± 5.2 segments and CE was able to visualize 13.4 ± 5.8 segments (P < 0.001). Administration of contrast agent significantly improved the assessment of LVEDV (feasibility SE: 36% vs. CE: 79%, P < 0.05). Conclusion Routine use of a contrast agent appears safe when used in patients having a new third generation LVAD and may enhance the diagnostic accuracy of transthoracic echocardiography in these patients. LV size determination can be obtained more often due to improved LV visualization using contrast agent.

Shear wave tracking: open chest versus closed chest

This paper describes an in-vivo pilot study in which the systolic myocardial stiffness of four pigs was measured with various acoustic techniques. We compare the propagation velocity of shear waves in open chest and closed chest experiments, in which the open-chest shear wave was either physiologically induced by aortic valve closure (N=3), or externally induced by acoustic-radiation force (N=1). The results of closed-chest versus open-chest recordings are consistent within 1 unit of standard error, whereas the acoustic-radiation force measurement showed lowest standard deviation (7% versus 13%).

The mitral annular displacement by two-dimensional speckle tracking: a new tool in evaluating the left atrial function.

Background The methods used to characterize the volume change and the deformation of the left atrium are highly dependent on technical factors and difficult to use in a clinical environment. The aim of this study was to demonstrate that mitral annular displacement by speckle tracking can be an alternative method to studying the longitudinal left atrial function. Methods Ninety study participants (54% men), with a mean age of 53(±15) years, underwent a complete echocardiographic examination, comprising two-dimensional, three-dimensional and tissue Doppler imaging (TDI). They were divided into normal individuals (35) and patients having an abnormal echocardiography (55). Results There was a very strong correlation between three-dimensional volumetric function and mitral annular displacement, both for the reservoir (r = 0.78; P < 0.0001) and contractile (r = 0.76; P < 0.0001) functions. The correlation with the longitudinal strain displayed an r = 0.87, P > 0.0001 for the reservoir and r = 0.81, P < 0.0001 for the contractile function. The systolic speed in pulsed TDI and the systolic displacement had an r = 0.83, P < 0.0001. Mitral annular displacement was a very good discriminator for normal versus abnormal participants [area under the curve (AUC) for reservoir = 0.872 and for contractile = 0.843; P < 0.0001], performing less well than three-dimensional (AUC reservoir = 0.892 and contractile = 0.915; P < 0.0001) or deformation (AUC = 0.921 and 0.903 respectively; P < 0.0001), but better than pulsed TDI (AUC = 0.807; P < 0.0001). The percentage error was ±15% for interobserver and ±12% for intraobserver variability. The time taken for displacement analysis was 9 ± 3 s for an experienced cardiologist and 12 ± 4 s for a beginner. Conclusion Mitral annular displacement by speckle tracking is a reliable and fast method to evaluate left atrial function. Given the strength of the correlations with strain parameters, it could be used as a surrogate measure of the deformation of left atrium.

Rheumatic multiple valve disease and severe asymptomatic arterial occlusion.

A 67-year-old female patient of North African origin, with a history of rheumatic fever during childhood, presented with exertion dyspnoea. The echocardiography demonstrated a severe mitral stenosis (3D area of 0.96 cm2, mean gradient = 8 mmHg) ( Panel A ; see Supplementary material online, Movie S1 ), severe aortic stenosis (maximal velocity = 4.6 m/s across the aortic valve; Panel B ) and …